The psychiatric and social consequences of coronary artery surgery

[Quality of life 2 years after coronary revascularization]

OBJECTIVE

To determine the impact of coronary revascularization surgery on patients' quality of life and to identify the presence of lifestyles representing a risk for coronary heart disease.

METHOD

We performed a longitudinal prospective study of 150 consecutive patients who underwent coronary surgery over a 6-month period. Perceived quality of life was evaluated before the intervention, at 6 months (n = 132) and 2 years later (n = 119). As measurement instruments, the MOS Health Survey (SF-36), the Nottingham Health Profile (NHP) and a questionnaire to identify lifestyles were used.

RESULTS

Most of the patients (95.8%) were men and were aged more than 50 years old (80.7%). Before surgery, significant physical limitations were present in 39.5%, comorbidity in 79%, prior infarction in 8.7% and three-vessel disease in 68%. The mean length of hospital stay was <or= days in 88.2% of the patients. The health benefits were greater at 6 months after the intervention than at 2 years, with better perceived quality of life in all dimensions of the instruments used to assess quality of life (p < 0.001). Comorbidity, the number of risk factors and postoperative complications showed no influence on quality of life 6 months after surgery. Two years after the intervention, 33.6% of the patients resumed their professional activity and most adopted healthier lifestyles.

CONCLUSIONS

Coronary revascularization substantially improves patients' quality of life, providing health benefits 2 years after the intervention.

Why do patients with heart failure suffer from erectile dysfunction? A critical review and suggestions on how to approach this problem

Chronic heart failure (HF) is an increasingly common cardiovascular disorder. The goal of health-care providers is to optimize quality of life in this population, including sexual health. Up to 75% of patients with HF report erectile dysfunction (ED). As HF is a condition with distinct physiologic sequelae, some unique organic and psychological factors contributing to ED in this patient population have been identified, along with risk factors common to the development of coronary artery disease, HF and ED. This review describes contributing factors to ED in the setting of HF and highlights treatment considerations for this distinct patient population.

Perceived Cognitive Function and Emotional Distress Following Coronary Artery Bypass Surgery

Many patients experience decrements in cognitive function and emotional adjustment following coronary artery bypass graft (CABG) surgery. Moreover, cognitive decline and emotional distress are often positively related. This study evaluated the cross-sectional and prospective associations of emotional and subjective cognitive complaints, to assess the hypothesis that they would be mutually reinforcing. Participants were 76 CABG patients recruited from Akron General Medical Center. Depression and anxiety symptoms and perceived cognitive difficulties were evaluated at a baseline postsurgical visit and re-assessed 5 months later. Emotional symptoms and perceived cognitive difficulties were significantly related both within and across time. After controlling for numerous potential confounds, baseline perceived cognitive difficulties predicted a more negative course of emotional symptoms during follow-up. Baseline emotional symptoms did not predict the course of perceived cognitive difficulties. Perceptions of cognitive decline may contribute to emotional distress in patients post-CABG.

Holocaust survivors coping with open heart surgery decades later: posttraumatic symptoms and quality of life

OBJECTIVE

History of prolonged traumatization has been associated with reduced quality of life (QoL) and difficulties in coping with major life-threatening conditions. We assessed the association between the impact of Holocaust experience (posttraumatic symptoms) and QoL of patients before and after an open heart surgery.

METHOD

Sixty-three Holocaust survivors were interviewed before open heart surgery (at admission), 52 at follow-up at 1 week, and 58 at follow-up at 6 months. The interview included background data, Impact of Event Scale (IES), Mastery scale, and QoL measured by the Nottingham Health Profile. Medical data were retrieved from the patients' charts.

RESULTS

The total IES score indicate a high level of posttraumatic symptoms at all the time points (close to a mean of 18), but there was a clear trend of changes in the avoidance subscale: At admission, the patients manifested lower avoidance compared with the levels after the surgery and at the follow-up. No significant differences in IES were found by Holocaust experiences. Significant improvements in most components of QoL were found at the follow-up. In multivariate analyses at each time point, the findings show that those with higher levels of posttraumatic symptoms are more at risk for problems in pain and mobility domains of QoL at admission, for emotional reaction after the surgery, and at the follow-up, these associations are only at trend level, while lower sense of mastery became significant.

CONCLUSIONS

The improvement in QoL despite persistence of the impact of the Holocaust may indicate that past severe prolonged traumatization does not necessarily reduce the survivors' ability to cope with and regain physical and psychosocial functioning after a severe life-threatening medical condition. This may be further generalized to other significant crisis situations in life, such as prolonged periods of stress, suffered by many populations throughout the world.

Report of the substudy assessing the impact of neurocognitive function on quality of life 5 years after cardiac surgery

BACKGROUND AND PURPOSE

The importance of perioperative cognitive decline has long been debated. We recently demonstrated a significant correlation between perioperative cognitive decline and long-term cognitive dysfunction. Despite this association, some still question the importance of these changes in cognitive function to the quality of life of patients and their families. The purpose of our investigation was to determine the association between cognitive dysfunction and long-term quality of life after cardiac surgery.

METHODS

After institutional review board approval and patient informed consent, 261 patients undergoing cardiac surgery with cardiopulmonary bypass were enrolled and followed for 5 years. Cognitive function was measured with a battery of tests at baseline, discharge, and 6 weeks and 5 years postoperatively. Quality of life was assessed with well-validated, standardized assessments at the 5-year end point.

RESULTS

Our results demonstrate significant correlations between cognitive function and quality of life in patients after cardiac surgery. Lower 5-year overall cognitive function scores were associated with lower general health and a less productive working status. Multivariable logistic and linear regression controlling for age, sex, education, and diabetes confirmed this strong association in the majority of areas of quality of life.

CONCLUSIONS

Five years after cardiac surgery, there is a strong relationship between neurocognitive functioning and quality of life. This has important social and financial implications for preoperative evaluation and postoperative care of patients undergoing cardiac surgery.

Temperature during coronary artery bypass surgery affects quality of life

BACKGROUND

The objective of this study was to examine the effects of temperature on a variety of indices of psychologic adjustment and quality of life.

METHODS

A total of 209 patients randomly received normothermic (warm) or hypothermic (cold) conditions during coronary artery bypass surgery (CABS), and a number of physical, social, and psychologic measures were assessed before as well as 6 weeks and 6 months after CABS.

RESULTS

Repeated measures analyses of covariance revealed significant temperature group main effects for anxiety (p = 0.008) and depression (p = 0.039), with the normothermic group obtaining lower anxiety and depression levels than the hypothermic group at both 6 weeks and 6 months after surgery. Additionally, among patients who entered the study with higher depression levels, those in the hypothermic group tended to have higher depression scores at follow-up compared with patients in the normothermic condition (p = 0.012). No temperature group differences were observed on other quality of life indices.

CONCLUSIONS

The results of the present study indicate that hypothermic conditions during CABS are associated with higher levels of emotional distress after CABS than normothermic conditions, particularly for patients with greater stress to begin with.

Psychological adjustment after cardiac transplantation

Psychosocial function improves after cardiac transplantation but the extent of improvement is not established. Neither are the factors established that account for variability in function between patients following successful transplantation. We therefore compared illness-related dysfunction in patients following orthotopic cardiac transplantation (OCT) with that in angina-free patients following coronary artery bypass graft (CABG) and stable patients in heart failure awaiting transplantation (HF). We also measured two factors that might contribute to variation in function: emotional distress and concern with physical symptoms. Psychosocial function was as good in OCT as in CABG patients and, in both, was better than in HF patients. Differences in emotional distress and in physical symptoms showed a similar pattern and contributed to, but did not completely account for, differences in function. Concern with physical symptoms contributed to variability in functional impairment in HF but not CABG patients; transplantation strengthened this relationship. The results show that successful cardiac transplantation enhances psychosocial function to a level comparable with that after CABG, and suggest targets for psychological or educational intervention to improve quality of life after transplantation in patients whose recovery is inhibited by concern about physical symptoms.

Facing uncertainty and possible death: the Christian patients' experience

This paper presents the hospital experience of a group of coronary artery bypass graft surgery patients. A description of the qualitative methodology is given. The participants' experience was identified as facing uncertainty and possible death. Excerpts from interviews are given. The participants coped with the situation by praying or having others pray on their behalf. Their uncertainty and possible death was affected by the conditions of: available support; environment; credible authority; information; belief; and their psychophysiological status at the time.

Influence of myocardial infarction, coronary artery bypass surgery, and stroke on cognitive impairment in late life

Relations between cognitive test scores in later life and prior myocardial infarction (MI), coronary artery bypass graft surgery (CABG), and stroke were examined for this study. Subjects were 3,734 Japanese-American men (80% of surviving Honolulu Heart Program cohort) aged 71 to 93 years at the time of cognitive testing. Impairment was defined as scoring below the 16th percentile on a validated cognitive assessment scale. Prior MI, stroke, and CABG were established using hospital surveillance, history, and record review. After adjustment for age, years of education, and years of childhood spent in Japan, men with prior stroke were significantly more likely than others to have poor cognitive performance (odds ratio 4.4, 95% confidence limits 3.0 to 6.7). History of > 1 stroke was associated with an odds ratio of 50 (95% confidence limits 10.5 to 238.3). There was no significant association between cognitive performance and > or = 1 prior MI or history of CABG. Time between events and cognitive function testing did not affect results. Analyses support a significant association between clinical stroke and persistent cognitive impairment, but fail to implicate CABG or MI.

State anxiety predicts poor psychosocial outcome after coronary bypass surgery

A prospective study was conducted to identify predictors of poor psychosocial adjustment 1 year after coronary bypass graft (CABG) surgery. Fifty-two of 61 consecutive patients (mean age = 66 +/- 9, 3 years, 76% men) were studied before and 1 year after surgery. Psychological, social, and surgical data were assessed. The roles of State and Trait anxiety, emotional reactions, and different coping modes were evaluated. At baseline the patients were divided into 3 groups according to their level of anxiety as assessed by Spielberger's State Anxiety Inventory (STAI). The 3 groups did not differ in any of the basic parameters, except for their subjective experience of symptoms of dyspnoea (p < .01), and quality of life (p < .0001) for the whole patient group 1 year after surgery. However, patients belonging to the moderate-anxiety and high-anxiety groups remained more psychologically distressed (p < .0001) and perceived a higher degree of residual angina pectoris (p < .0001) than did patients who did not display anxiety preoperatively. Dividing the patients into groups according to their answers to the other measures of psychological distress or negative coping strategies yielded similar results. The results indicate that the SATI is a valuable instrument for identifying risk patients for poor adjustment after CABG surgery.

Psychological effects of cardiac surgery: a review of the literature

Cardiac surgery is now offered to more patients than ever before. Different age groups are affected by different forms of the disease and, as a result, patients range from new born infants to those in their eighties. In recent years attention has begun to focus on the psychological effects of such surgery. This article considers current research into the cognitive, psychiatric and psychological changes associated with cardiac surgery, with specific reference to coronary artery bypass grafting (CABG).

Prediction of quality of life after coronary artery bypass graft surgery: a review and evaluation of multiple, recent studies

OBJECTIVE

To review studies predicting psychosocial outcome after coronary artery bypass graft surgery (CABG).

METHODS

Seventeen prospective studies, appearing in the MEDLINE and PsycLIT data bases between 1986 and 1996, were reviewed regarding objectives, methodological issues, results, and clinical relevance.

RESULTS

All studies reported that psychological factors bad predictive value. In particular, preoperative anxiety and depression predicted postoperative psychological maladjustment; social support, preoperative feelings of control, denial, and optimism contributed to psychological adjustment.

CONCLUSIONS

Many specific psychological outcomes seem to be best predicted by preoperative assessment of functions in that specific area, especially in the case of anxiety and depression. Furthermore, personality factors including denial, optimism, control, and the need for support appear to be predictors of psychological outcome. Appropriate identification of predictive factors might improve the development of individually tailored interventions for patients at risk of postoperative psychological problems.

Self-reported depression in patients with coronary heart disease

BACKGROUND

Assessing depression in cardiac patients is challenging because somatic symptoms of depression may be the result of physical illness. This study examined self-reported symptoms of depression in patients with cardiovascular disease.

METHOD

Three hundred six patients with cardiovascular disease completed the Inventory to Diagnose Depression (IDD), which is a self-report depression scale.

RESULTS

Practically all patients reported some symptoms on the IDD, but only a small number had scores in the range suggestive of depression. Somatic symptoms did not contribute disproportionately to depression scores but affective and cognitive symptoms were stronger indicators of depression in these patients. Factor analysis identified one factor that represented a general syndrome of depression.

CONCLUSIONS

The results suggest that the IDD has promise as a measure to screen for depression in cardiac patients.

Psychosocial aspects of coronary artery disease related to military patients

OBJECTIVE

Coronary artery disease (CAD) is a major cause of nontraumatic morbidity and mortality in military personnel. Most studies of the psychosocial impact of CAD have dealt with civilian populations. The purpose of this paper is to highlight differences between military and civilian populations with CAD in 4 areas: depression and anxiety, social support, return to work, and stress.

METHOD

A computerized literature search from 1985 to 1995 using the search terms "stress," "cardiovascular," "cardiac," "depression," "military," "anxiety" and "psychosocial" was undertaken. Controlled and prospective studies of civilian patients were selected along with relevant studies involving military populations.

RESULTS

Unique characteristics of the military may be important factors in affecting the psychosocial outcome of military patients with CAD. These characteristics include a high level of denial of illness, strong social supports, a powerful military work ethic, and stressful situations unique to the military.

CONCLUSIONS

Most studies of the psychosocial impact of CAD are based on civilian populations. A review of available studies suggests that little is known about how military patients adapt to CAD, particularly with regard to symptoms of depression and anxiety, social impairment, and rates of return to work. Studies in this area are needed regarding the psychosocial aspects of CAD in military populations.

The effects of cardiopulmonary bypass temperature on neuropsychologic outcome after coronary artery operations: a prospective randomized trial

The effect of systemic perfusion temperature on postoperative cognitive function was investigated in 96 adult patients undergoing elective coronary revascularization with cardiopulmonary bypass at 28 degrees C, 32 degrees C, or 37 degrees C. Neuropsychologic performance was assessed 1 day before the operation and 6 weeks after the operation. Five tests were adapted from the Wechsler Adult Intelligence Scale and two from the Wechsler Memory Scale.

RESULTS

No patients had major neurologic complications. Ninety-three patients completed the five Wechsler Adult Intelligence Scale tests, but only 70 went on to complete the Wechsler Memory Scale tests as well. In these, there was an effect of cardiopulmonary bypass temperature on the number of neuropsychologic tests in which there was a preoperative to postoperative deterioration (p = 0.021), the number with bypass at 37 degrees C being significantly greater than the number with bypass at 32 degrees C (p = 0.015). Subsidiary analyses using a multivariate linear model examined the effect of cardiopulmonary bypass temperature on the magnitude of change, with or without allowing for other possible confounding influences. There was an adverse effect of normothermic (37 degrees C) versus moderately hypothermic (32 degrees C) perfusion---more convincingly displayed in the analyses of all seven scores rather than just the Wechsler Adult Intelligence Scale scores. Further cooling to 28 degrees C conferred no additional benefit in terms of cognitive function. The importance of the deterioration is open to question.

Subjective complaints versus neuropsychological test performance after cardiopulmonary bypass

The study by Newman et al. (Journal of Psychosomatic Research, 1989) compared subjective reports of cognition with assessed cognitive performance in patients one year after coronary artery bypass surgery. The current study reinvestigated this relation in a larger and more heterogeneous group--90 cardiac patients six months after cardiopulmonary bypass--using a more extensive checklist of subjective complaints and different neuropsychological tests. In agreement with previous research, the patients who reported complaints in specific cognitive areas were not found to have impaired cognitive functions as assessed with appropriate neuropsychological tests. The patients who reported deterioration in cognition after surgery were found to have higher levels of depression and state anxiety. These differences were significant for almost all evaluated cognitive functions. An alternative explanation of the relationship between mood and cognitive complaints based on personality traits, i.e., neuroticism, is offered.

Percutaneous transluminal coronary angioplasty: clinical and quality of life outcomes one year later

BACKGROUND

The quality of life status of patients prior to and following percutaneous transluminal coronary angioplasty (PTCA) has not been comprehensively investigated.

AIM

This study was carried out to determine the effect that PTCA has on patients' quality of life.

METHODS

Data on 209 patients were collected one day pre-PTCA and at a mean of two and 11 months post-PTCA. Data on symptomatic status, functional capacity, life satisfaction and psychological well-being were analysed quantitatively. Clinical outcomes, patient perception of PTCA and employment status wee analysed by descriptive statistics.

RESULTS

Highly significant improvement in all quality of life measures was found at the early follow-up (p < .001). This improvement was sustained at the late follow-up. At the late follow-up, 58% of patients felt that PTCA had been very beneficial to their health and well-being, and 79% of workers had returned to work. PTCA was primarily successful in 91% of vessels dilated. There were no procedural-related deaths, 12 patients (6%) developed acute occlusion and three patients (1.5%) experienced myocardial infarction (MI). A symptomatic restenosis rate of 16% was found, including 19 patients (9%) requiring repeat PTCA and 14 (7%) undergoing coronary artery bypass grafting (CABG).

CONCLUSION

These findings suggest that, after PTCA, the majority of patients experienced improved quality of life which was sustained one year later.

Symptoms reported by older and middle-aged adults after coronary bypass surgery

Knowledge of the most prevalent symptoms after coronary artery bypass surgery (CABS) can be used to assist patients to anticipate recovery. The purposes of this study were to describe the prevalence of symptoms during the first 6 weeks after CABS, to assess changes in the number and types of symptoms, and to compare symptoms in older and middle-aged adults. The most prevalent symptoms during hospitalization (Time 1) were pain, edema, wound drainage, fever, and fatigue. In the third through fifth postoperative weeks (Time 2), the most prevalent symptoms were pain, edema, sleep problems, fatigue, and wound drainage. At 6 weeks (Time 3), sleep problems, edema, pain, fatigue, and shortness of breath were the most common. Number of symptoms decreased significantly between Times 1 and 3. All symptoms were more prevalent at Time 2 than at Time 1 and less prevalent at Time 3, with the exception of sleep problems, which were reported more frequently at Time 3 than at Time 1. The most persistent symptoms were edema, fatigue, sleep problems, pain, and shortness of breath. Significantly more middle-aged adults than older adults reported anxiety at Time 2. No other age-related differences were found. Implications for nursing practice and research are discussed.

Medical and Neuropsychiatric Complications Associated with Use of the Intraaortic Balloon Pump

We conducted a retrospective chart review of 195 consecutive patients who had an intraaortic balloon pump (IABP) placed at the Massachusetts General Hospital during the calendar year 1988 to determine the incidence of complications associated with IABP treatment. Demographics, medical and psychiatric history, hospital course, medical and neuropsychiatric complications observed while on the IABP, pharmacological management, and outcome were recorded. Patients ranged in age from 26 to 81 years, with a mean of 62 years. Women comprised only 25% of the sample but had a mortality (40%) twice that of men (20%; p = 0.008). An IABP was inserted for cardiogenic shock in 52% of patients, for refractory angina in 36%, and intraoperatively in 12%. Patients were treated with an IABP for a mean of 4.4 days (range, several hours to 36 days). Complications included delirium (34%), mortality (25%), peripheral vascular insufficiency (17%), bleeding (14%), acute renal failure (14%), infection (8%), and stroke (4.6%). Delirium was associated only with a history of seizures and with development of a residual organic brain syndrome. Mortality was associated with female sex, cardiogenic shock, and number of complications present per patient. Vascular insufficiency was associated with female sex, history of peripheral vascular disease, valve replacement surgery, and mortality. Residual organic brain syndromes were more common in patients in whom delirium developed. A review of the literature on complications associated with IABP therapy is provided. This study highlights the common but previously unrecognized complication of delirium in IABP patients.

The measurement of health-related quality of life: major dimensions identified by factor analysis

The measurement of quality of life is becoming more important in the evaluation of medical technologies and pharmaceuticals. Particularly when the several available therapies have similar effects on survival, quality of life measures may help decide which should be the therapy of choice. The Recovery Study utilized a multidisciplinary array of indicators of health-related quality of life and recovery. This paper reports factor analyses of 58 outcome measures on a study group of 469 persons who had undergone coronary artery bypass or cardiac valve surgery 6-months previously. The factor analyses revealed 5 orthogonal dimensions. We have named them: low morale, symptoms of illness, neuropsychological function, interpersonal relationships, and economic-employment. The data argue that health-related quality of life is a multidimensional construct, and that these dimensions can be measured quantitatively with relatively simple interview and questionnaire approaches. The next research step is to determine whether the five dimensions of post-operative quality of life have different pre-operative predictors, and whether intervention on these predictors can improve the recovery and rehabilitation process.

Psychosocial adjustment before and after coronary artery bypass surgery

Twenty-eight consecutive male patients were examined a few days before, and again twelve months after, coronary artery bypass surgery. The evaluation included the patients' psychological distress, psychosocial adjustment, cardiac state, personality and family relations. Before surgery the patients were relatively well adjusted, despite being severely disabled physically. On the follow-up evaluation the cardiac state improved significantly on every index examined. On the other hand no change occurred in the psychological distress, personality and family relations. Significant post-operative improvement was found in some of the domains of the psychosocial adjustment, but not in others.

Coronary risk factor outcomes following coronary artery bypass surgery

The coronary risk factor status of patients prior to and following coronary artery bypass surgery (CABG) has been poorly investigated. Two consecutive series of CABG patients were surveyed following CABG. One hundred and thirty patients were assessed immediately following CABG and 530 patients were assessed 12-30 months following CABG. For the long-term post-CABG group, over 80% of those who had ever smoked had ceased. Sixty-four per cent of these males and 50% of females were classified as being overweight. Twenty-five per cent of males and 34% of females reportedly had high serum cholesterol (i.e. greater than or equal to 6.5 mmol/L). Comparing these CABG data with age-adjusted National Heart Foundation Risk Factor Prevalence Survey data, there was a higher prevalence of ex-smokers, overweight, hypertension, and elevated cholesterol. It was concluded that on most coronary risk factors, except for smoking, these CABG patients had a worse profile than the general Australian community. This problem warrants further research and the development of appropriate treatment programs.

Subjective reports of cognition in relation to assessed cognitive performance following coronary artery bypass surgery

Evidence has accumulated to indicate that a proportion of patients who undergo coronary artery bypass surgery (CABS) do develop significant cognitive deficits. This study examines whether those patients who report cognitive deterioration after CABS do show cognitive changes as assessed by neuropsychological testing. The patients who considered that aspects of their cognitive function had deteriorated, were not found to have reduced functions as assessed on appropriate neuropsychological tests. When mood state was examined, it was found that those who report a deterioration in a particular cognitive function, tended to have significantly higher levels of depression as assessed by the Beck Depression Inventory and, to a lesser extent, have higher levels of state anxiety. These findings emphasise that subjective reports of cognitive function following CABS do not reflect actual changes in cognition but rather appear to be sensitive to mood state.

A prospective evaluation of the psychosocial effects of coronary artery bypass surgery

Eighty-nine patients were prospectively studied to determine psychological and psychosocial impairment prior to and after coronary artery graft surgery (CAGS). Psychological morbidity prior to surgery was high, with one-third having clinically significant levels of depression and/or anxiety symptoms. Scores on the Psychosocial Adjustment to Illness Scale indicated a generally high level of psychosocial impairment pre-operatively, with vocational and domestic functioning being most severely affected, social and sexual functioning being less impaired, and extended family relationships being largely unaffected. In general, there was a significant reduction in psychological morbidity and an improvement in psychosocial functioning at 6 months, which remained at 12 months. Vocational and domestic functioning showed the greatest improvement. Sexual and social functioning showed modest improvements overall, with significant numbers reporting residual impairment due to their heart disease. These findings add to a growing body of evidence demonstrating generally favourable psychological and social outcome following CAGS.

Prediction of outcome after coronary artery surgery

Coronary artery surgery is usually successful in relieving angina but benefits for quality of everyday life are sometimes disappointing. Generalized linear inter-active modelling (GLIM) was used to examine pre-operation predictions of psychological and social outcome 3 and 12 months after coronary artery surgery. The study identified predictors of return to work (social class, previous employment status), psychiatric outcome (pre-operation mental state) and social adjustment (pre-operation mental state, age, social class). Although our analysis of potential predictors of 1 yr outcome at 3 months after surgery was less detailed, early convalescence is likely to be the best time for clinical identification of those at risk of poor long term outcome. The findings have implications for selection and preparation for surgery and identification of those who might benefit from extra rehabilitation.